Communication Difficulties: Update

Over the lifetime of my blog I have talked about Little Bear’s communication difficulties quite a bit: first of all in Living with Speech and Language Difficulties then later in A bit of a rantAnother try at SaLT and SaLT, EP & an Assembly. In the most recent posts I have focussed on our quest for formal speech and language therapy rather than Little Bear’s communication needs per se. As therapy has been going pretty well, I thought it was time for a look back at the development of Little Bear’s communication and how priorities have changed over time.

When Little Bear first arrived his primary communication need was to develop his listening and attention skills. Little Bear simply wasn’t tuned in to language – he ignored it in pretty much the same way you would ignore background noise. He didn’t see the point of it and sadly I don’t really think he thought it bore any relevance to him. Little Bear’s listening skills were poor which impacted on his ability to understand language and on our ability to get him to co-operate.

I can remember wandering around a beach with him during Introductions. In my typical SaLT fashion I talked to him as we wandered. I pointed things out and named what we saw. Little Bear found this completely alien and tried to shrug me off like a nuisance insect. I think he even took to shushing me. Equally he did not respond to his name or any other command. Getting him to behave and keeping him safe was incredibly difficult without the use of language.

Over time we worked on this, mainly by keeping listening fun to start with – lots of drawing his attention to passing noisy things such as aeroplanes or dogs or sirens. I definitely found that in order to engage Little Bear with listening, we had to start with non-language tasks. We were probably quite silly and playful too, which helped.

As Little Bear’s listening skills improved a bit, we were able to work on his comprehension at the same time. Probably as a result of the listening and attention issues, Little Bear’s understanding of language was certainly delayed for his age. We noticed that he often said “what?” and needed us to repeat things for him, sometimes several times. We all reduced our language from the beginning to help him understand as there was a clear pattern that the more complex the vocabulary or the longer the instruction/ explanation the more Little Bear struggled.

Little Bear’s vocabulary was very poor for a 3 and a half year old so we did lots and lots of modelling which has developed both his understanding and his expressive language. I think if I had to pick one strategy that has been the most effective I would say modelling. There are several reasons. Firstly you don’t need any equipment to model language – you can do it anywhere and completely spontaneously which makes it very practical within busy family life. You can easily work to your child’s level – either just modelling back their sentence without errors or by adding in an extra word to extend their sentence length. I would often have a couple of targets in mind at any one time e.g. for Little Bear to understand the concepts of same/different, so would model those concepts each time an opportunity arose in play or just when out and about.

You can use modelling to develop any aspect of communication – initially I used it mostly for vocabulary and sentence building. I have moved on to using it for grammar and speech sound accuracy. I don’t think I would have predicted that it would be as effective as it has been: Little Bear’s progress has been huge. The great thing is that it is a very positive approach and at no point has it felt like I’ve been nagging or correcting Little Bear. In fact he got so used to me using the strategy that if I didn’t model back his sentence after him he thought I wasn’t listening properly and would repeat himself until I did! This is in stark contrast to the boy who didn’t want me to talk to him at the beach.

Little Bear’s comprehension is now patchy on formal assessment. His understanding of basic concepts such as hot/cold, first/last, same/different is within the expected range. His understanding of different sentence types is at the low end of average and his understanding of complex sentences continues to be below expectations. However, in everyday life we have noticed leaps of progress.

I recall one day driving past some electrical cables that had come down in a storm. My natural instinct was to point them out and tell Little Bear about them but I remember stopping myself because I knew that he had no idea what electricity was and I wouldn’t be able to find a way to explain it that he would be able to follow. These days his wider understanding of life is growing all the time. I recently mentioned London in passing and he said “they had a nasty fire there, people died” and another time we were looking at a map and I said “that country is America” and Little Bear piped up “is that where Dobald (Donald) Trump is building his wall?”. He is full of surprises these days and it’s brilliant to see his understanding of complex concepts developing all the time.

Little Bear’s ability to express himself on arrival was also poor. I remember him saying “you came back” on the second day of Intros and this being quite a momentous sentence. On the third day he said “you came back again” which was poignant and sad and lots of things but also the longest sentence I heard him say for a while afterwards.

I don’t think it is any coincidence that Little Bear’s behaviour was as it was. His lack of ability to ask questions, negotiate, explain himself and talk himself out of situations certainly lead to a high level of frustration and anger and the unavoidable need for some very expressive behaviour.

For a long time Little Bear expressed himself through pointing and enthusiastic use of “that”. He had some stock sentences that all followed the same structure: I go running, I go playing, I go sleeping. He used the words he did have creatively to get his points across e.g.“bik” (big) meant lots, tall, deep, full, massive.

Little Bear’s expressive language now comes out as being within the expected range on the Renfrew Action Picture Test. I don’t honestly think this is an entirely accurate representation of his abilities but he does use lengthy compound sentences and I have noticed that being able to do so has helped him in many ways. Just today he had his IPad in the car and I heard a crash as though he had thrown it on the floor. “Did you throw that?” I asked him, “No Mum, I tried to put it on the seat but you went too fast and it slipped on the floor”. I have no idea if this was true but I had to credit him with the good explanation. Previously I might have wrongly assumed he had chucked it and he might have got into trouble and not been able to defend himself. Having improved language skills has definitely helped with behaviour in more ways than one.

A big indicator of Little Bear’s progress with his speech and language skills is that now he is having formal SaLT our agreed priority is his speech sound system. It is generally agreed that language should be the main priority with speech being more of a secondary skill. Our decision to focus on his speech is due to his language skills being good enough and his speech now being the biggest barrier to his communication. It is funny how priorities have changed.

Little Bear’s speech was pretty much unintelligible at the start. Then we tuned in and as he didn’t have many words it didn’t take long for us to be able to translate. That was all well and good until his vocabulary sky rocketed and then we were back to having no idea what he was trying to say again.

Using mainly the modelling strategy we have targeted voiced/ voiceless confusion (“beas” for ‘peas’), articulation of ‘l’ (there was a little more than modelling involved in that one but not much), production of l clusters (pl, cl, sl, fl etc) and some random inconsistent/ storage errors e.g. “gog” for ‘dog’, “nogat” for ‘yoghurt’, “mu-ey” for ‘money’, “di” for ‘dummy’ etc. However, despite all that, at the start of SALT, Little Bear was still fairly unintelligible to the therapist at the age of 4 and a half. It transpired that his vowels were jumbled which was resulting in very unusual sounding speech – his teacher had even asked me if he was foreign.

At this point, although I am a SALT and had worked on lots of aspects of Little Bear’s communication myself, I was glad and relieved to have another therapist on board. Vowels are complex, they are in all words and I couldn’t really see the wood for the trees. I was pleased to have somebody to defer to for clinical decision making. She didn’t really know where to start either so after identifying which vowels were going wrong, we pretty much just plumped for one to have a go at. It was ‘eye’ as in pie, pipe, kite, nine, five etc (for non-SaLTs think about how they sound, not how they are spelled). It turned out that Little Bear could make this sound and he could say it correctly after a consonant e.g. pie but as soon as a consonant was added after it (pipe) the vowel distorted. In this example it became “pap”. Little Bear could hear the difference between pipe and pap which helped.

Once we had figured this out and done one session of therapy, Little Bear had cracked it and was spontaneously generalising the sound. We were both unprepared for it to be that quick. I was also surprised by how often that vowel crops up in English and therefore what a difference working on it made to his intelligibility.

We have since worked on ‘ow’ as in house, mouse, brown which were coming out as has, mas, bran. Little Bear acquired ‘ow’ in much the same way as ‘eye’. We then tried ‘err’ for no particular reason other than because it was another he couldn’t say but for some reason that one just isn’t coming so we have switched to ‘ay’ as in pay, plate, eight. Little Bear can say it in words but is not generalising it as yet. I am now getting a bit tangled up with which vowels I need to model for him!

The formal therapy is pretty good though it is not completely plain-sailing.

I had thought it would be helpful for me to keep in touch with the therapist via e-mail between appointments so I could keep her updated and take away the need for her to change her session plan on our arrival – this happens most weeks due to Little Bear’s unexpected/erratic rate of progress. However, apparently this would be against policy which seems odd to me. I frequently used to use e-mail to keep in touch with parents and think this is a missed opportunity.

Also, it turns out that Little Bear is now entitled to therapy in school because he has top-up funding. However as his speech requires specialist input from a therapist only, he has been deemed more appropriate for clinic therapy. I suggested that maybe the funding could be used to train school staff to work on his language targets alongside this. Apparently it cannot be done because the school team and the clinic team are separate and you cannot be on two lists at the same time. Whilst I get this, I can’t help feeling frustrated at the lack of flexibility and feeling a little like he’s missing out on his entitlement. A system with two rigid lists does not have children and their individual needs at the centre of it.

Either way, Little Bear continues to make fabulous progress and for that I am extremely thankful.

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Communication Difficulties: Update

Schools Out

For the past fortnight the Bears’ school has been in transition, with each class getting settled in their new classroom and with their new teacher. Things seem to have gone fairly smoothly but I checked in with Little Bear’s teacher yesterday, just to be sure.

I wrote a few weeks ago in Support about school (and us) having secured funding top-up funding for Little Bear. I have recently found out that the school have been able to advertise for a TA and that they have employed somebody and this person will provide Little Bear with 20 hours of support per week. Obviously this is great. They will work from 8:30 am so will be able to greet him and will finish at 12:30 meaning he gets support for some of his lunch time – a flashpoint when things often go awry. He will have 1:1 or small group support available for all his core subjects.

I’m very pleased about this.

Things are never perfect though and there are a couple of little niggles at the back of my mind. Firstly I didn’t expect the TA to be anybody that I knew. It turns out she is a parent of children in the same school. I don’t know her but I know of her as she has previously volunteered in the school, in fact in Big Bear’s class. She used to hear them read and was quite infamous amongst the parents for making slightly judgemental comments in their take home books.

I have noticed that if you smile at her she tends to look the other way.

I feel a little uncomfortable that she is a parent too and that she is going to know lots of things about Little Bear’s background and his behaviour and his learning needs. I have to assume that she is a consummate professional.

I am going to need her to start speaking to me though because I consider there to be a team around Little Bear, consisting at the moment of the teacher and myself & Grizzly, and Mrs. C will soon be an integral part of that. We will need to work closely together and will need to be consistent in our approaches. I am trying to keep an open mind and am hoping that we can achieve the partnership that I’m aiming for.

Little Bear’s teacher and I have agreed to let Mrs C settle in and get to know Little Bear and then for us to have a meeting in maybe the third week. This will help us all get up to speed and hopefully signal the start of a good working relationship.

Unfortunately Mrs C has been tied up in her old contract and has not been able to meet Little Bear during his transition weeks. The school have provided a different TA for the interim. Little Bear has bonded with her well and has been happy to work with her. His teacher and TA have been impressed with what he has been able to achieve with support. He has concentrated well and been co-operative.

There is an obvious risk that the inconsistency of returning to a different TA could throw Little Bear. There is a risk that he may not bond with her as easily and may not be as keen to work with her. I hope this is not the case and it is just my natural tendency to think of all the things that could possibly go wrong talking. I am keeping everything crossed that Mrs C’s firm approach will be ideal for him and that he will work with her quite happily.

My chat with the teacher also revealed that whilst things are going pretty swimmingly in the mornings, the afternoons are a different story. Little Bear does not have support in the afternoons. He seems to be doing ok with accessing the carpet time plenary session but when the children are meant to be doing some independent recording it sounds as though he is doing whatever he fancies. I can see why he would because he cannot do independent writing yet and it sounds as though he is struggling to occupy himself with something constructive and is tending to get into a bit of bother instead. The reduced supervision will be difficult because we know he has a tendency to lash out where verbal negotiation is needed and we also know that the other children have a tendency to purposefully push his buttons. With the best will in the world the teacher cannot see everything at once and it is quite a full on class. I can see why things are going belly-up.

It sounds as though the one thing that will occupy him is the IPad… I really don’t want him to spend every afternoon glued to a screen. Hmm.

Also, it seems as though Little Bear is not being particularly co-operative with things such as tidying up when asked. This is interesting because he generally will tidy things away if I ask him to at home. Ever the opportunist I suspect he is just doing what he can get away with. It is so important that we all handle situations like this in the same way otherwise Little Bear picks up on the inconsistency. When he detects that the boundaries aren’t particularly clear or firm I do think that his anxiety rises and his behaviour deteriorates.

My plan is to let the holidays happen and to send an e-mail ready for the start of term with some thoughts on things that might help. Perhaps it would be helpful to have a bank of activities that would occupy Little Bear when he can’t access the work – things that would provide him with a bit more variety and learning potential than the IPad alone. I’m also wondering about alternative recording options for him such as recordable switches and talking tins, until his writing has developed a bit more. I will need to be clear about how we manage it if Little Bear refuses to tidy up or turn the IPad off when asked.

It could be that afternoons without support are not ok but we’ll have to see how things go.

The conversation made me even more thankful that we got the funding that we did and made me shudder to think what things could have been like if Little Bear was trying to manage whole days without tailored support.

I need to forget about it all for now though: school’s out! I have no idea how a whole academic year has gone already. Time really does fly.

When I tucked Little Bear in tonight I told him how proud I am of him and how well he has done at school. I know it hasn’t been plain-sailing but overall I am very happy with how his first year has gone. He’s done brilliantly. Over the summer we can really focus on his speech and keep trucking with the reading and writing. I know school is out but the learning needs to continue. He’s pretty keen these days and we can easily weave lots of learning into the things he chooses to do.

So far I am feeling keen and enthusiastic for my task ahead but I think we should take bets as to how long I will last before I’m tearing my hair out and counting the days until term starts again!

 

 

Schools Out

Living with Speech and Language Difficulties

As I was driving Little Bear home from preschool today we had a very frustrating conversation. It went like this:

Little Bear: I want that one Mum

Me: That what?

LB: That button.

Me: Ok. Which button?

LB: That one (pointing)

Me: I can’t see matey.

LB: That one (pointing).

Me: I’m driving. I can’t see. Which one?

LB: THAT ONE!!!

Me: Try to use a word to tell me

LB: That button.

Me: (Trying a different approach) ok. Is it on the steering wheel?

LB: No.

Me: Is it the radio?

LB: Yes

I switch from CD to radio.

LB: Not that!!

Me: You didn’t mean the radio?

I switch back to CD.

LB: I want that one.

Me: That what?

LB: That button (pointing)

Me: (Trying not to sound annoyed) we’re nearly home. When we stop you can show me.

It was the skip button. He wanted a different track on the CD.

It’s very frustrating because he knows what he means; he just really struggles to find the right words to explain himself. I think in this case he was struggling to understand why I couldn’t just look at where he was pointing (I had sneaked a peak but there are a lot of buttons in a car, all in a very similar place) and why I didn’t just know by the powers of telepathy.

Sometimes, Little Bear does know the word he needs but I still struggle to understand him because his speech is unclear too. The evening before the CD incident, we had experienced one such struggle. My brother and I had picked Little Bear up and he was very excitedly trying to tell us what he had been up to. “I find dasha” he said. “You found a dinosaur?” “no, da sha” “erm, dancer? Dasher?” “DA SHA!”. I’m not sure how many times he repeated it. In the end I had to say that my ears weren’t working properly and then e-mail his keyworker to try to get to the bottom of it.

Treasure! The word was “treasure”. As soon as we had figured it out it was obvious. I couldn’t believe I hadn’t clicked at the time. The trouble is that in the early days, Little Bear had so few words that I knew exactly how each one sounded. Once I had tuned in, I could understand probably 95% of what he said. However, since then, he has had such an exponential growth in his vocabulary that it’s impossible to keep up. His longer sentences and myriad of words mean that his speech sound difficulties have become more apparent. Consequently I can now probably only decipher 80 to 85% of what he tries to say, bless him.

I must clarify that last paragraph though because obviously the improvement in his language is a good thing. Back at the start of life with Little Bear I had a few shock moments when I realised how profound Little Bear’s lack of life experience was and what a huge impact this had had on his language development. At 3 and a half years old, even with a recognised language delay, I still expected him to know basic vocabulary e.g. cow. But he didn’t. We saw a cow and he said “horse”. We saw a horse and he said “horse”. We had to teach him that they were two different animals with different names. We talked about a cow making milk. It was quite a revelation for him. We saw a train and he said “bus”. Every vehicle on the building site was a “digger”. I looked back to when Big Bear was a similar age and could reel off “dumper truck”, “bale fork”, “roller”, “teleporter” and I saw a word mountain towering in front of Little Bear.

The mountain wasn’t just made of nouns but verbs, concept words (big, same, hot etc), connectives, pronouns. And not just words on their own but words waiting expectantly to be ordered into sentences, preferably with some consideration for grammar. It was a big mountain.

Well, Little Bear would have said it was “bik” and he didn’t know “mountain”. In those days, everything was bik. “Bik” could mean “I want A LOT of ketchup” or “I want my water pistol FULL” or “that water is DEEP” or HUGE or MASSIVE or TALL. But Little Bear only had the one word for size or quantity so “bik” it was. “Bik” shows me how Little Bear has scaled that forbidding mountain, how he has clawed his way up it against all odds. “Bik” has gone now, replaced with its correct counterpart “big” and all the words in capitals are now part of Little Bear’s every day vocabulary.

Back when we were still in the foothills of vocabulary mountain, I found it hard to tell whether we were making progress or not. People would say “isn’t his language coming on?” and I would say “is it?!” and feel mildly ridiculous that as a Speech and Language Therapist I wasn’t a bit clearer about this. However, after a while it was patently obvious that we were climbing fairly rapidly upwards. Sometimes I’d leave him for a couple of hours (with grandparents or at preschool) and feel as though he had more language when I came back than I had left him with. The length of his sentences is increasing all the time, he is continuing to grow his vocabulary and I can see signs of change in his speech.

However, the mountain we are scaling is massive and as the CD example shows, there is some way to go yet. Amongst other things, we need to work on auditory memory. Like many children with Speech and Language Difficulties, Little Bear is much quicker to learn through his visual channel than any other way. He has a good sense of direction; he can remember where he has seen items so is good at finding things; he can learn a visual sequence e.g. the I pad code; he can solve visual problems e.g. how to open a lock. In comparison, his auditory skills are much weaker. It’s not really a surprise seeing as though less than a year ago he wasn’t really tuned in to language at all. He wasn’t used to paying attention or listening to the spoken word. Consequently his comprehension of language is also delayed. We have always needed to simplify instructions and be prepared to repeat them again and again to give Little Bear chance to process them. He has made enormous progress with this too but I am becoming aware that his auditory memory is not really providing him with the support it should. Auditory memory is meant to be a kind of holding pen for words that come into your brain from your ears. It should sit the words down on a virtual bench, all in the right order and keep them there for a few seconds until other parts of the brain have had chance to make sense of them. Little Bear’s bench is a bit wonky though, maybe it has a leg or two missing and the words can’t sit on it. They keep falling off before he’s had chance to figure them out and some of the words probably don’t even make it onto the bench at all. Repetition is crucial for him: it maximises the chances of the words getting onto the bench.

I think Little Bear’s difficulties with learning to count could be due to this faulty auditory bench. He has learned a few number names but he just can’t hold them on his bench for long enough or in the correct order to be able to retain the sequence.

Luckily, auditory memory is a bit like a muscle and can get stronger with exercise. This strengthening is hanging above us on the language mountain.

We also need to work on Little Bear’s sound awareness system. He finds longer words a bit tricky and misses syllables out so that “guitar” and “car” end up sounding the same. He needs to begin to understand that words start with different sounds. He needs to learn to make a “l” sound and that sharp and map end with ‘p’, not ‘k’ or ‘t’. He needs to learn that some sounds are noisy and some are quiet. He needs to learn how to say his name so that people can understand it. He needs to learn that “4” is not the answer to “what’s your name?”. That answer goes with “how old are you?”. “How old are you?” is not the same as “how are you?”.

It’s a big mountain.

Most of all, we want him to be able to express all of those thoughts and ideas and wishes that are currently held captive in his brain. We know they are there, clamouring to get out but the exits are currently blocked by inadequate language skills. It is upsetting to see him get frustrated and to try to chat with his peers but often fail at this because they cannot understand him.

We continue to scale the sheer rock faces though – so far there has thankfully been no plateau to wait around on. I cannot help but turn every activity into a language learning opportunity and I’m probably modelling words in my sleep! It’s a big mountain but we will reach the top. One day.

 

 

If you have any concerns about your child’s communication skills, or want to know more about the role of the Speech and Language Therapist, check out my Guide to Speech and Language Therapy on the Adoption Social: http://theadoptionsocial.com/blogless-blogging/speech-and-language-therapy-a-guide/

 

Living with Speech and Language Difficulties